Effectiveness of a Delirium Prevention Bundle in Hospitalized - PowerPoint PPT Presentation

Evaluating the Feasibility and Effectiveness of a Delirium Prevention Bundle in Hospitalized Critically Ill Patients Claudia DiSabatino Smith, PhD, RN, NE-BC Petra Grami, BSN, RN, CVRN II

Learning Objectives • Describe the components of a prevention bundle that was designed to decrease the incidence and duration of delirium in hospitalized critically ill patients. • Discuss findings of a study that tested the use of a delirium prevention bundle in hospitalized critical care patients.

Purpose The purpose of the research study was to evaluate the effectiveness of a delirium prevention bundle in reducing the incidence of delirium in hospitalized critically ill adult patients.

Research Questions 1. What is the feasibility of Staff RNs effectively assessing patients for delirium using the CAM- ICU? 2. What is the proportion of patients with delirium? 3. Does an intervention bundle prevent or reduce delirium? 4. Are there components of the bundle that are problematic to achieve? 5. Which components of the intervention bundle contribute significantly to reduce or prevent delirium?

Methods • Design – Prospective, multiphase – Interventional cohort study • Setting – Houston, Texas, USA – Large tertiary care center – Two similar medical-surgical ICUs • Sample (n=782 intervention study) – 23,430 observations (8,070 for the intervention unit) - patients have <30 days of observations.

Similar Units Average Case Mix Index Month Control Unit Intervention Unit January 2.836 2.707 February 2.894 2.496 March 2.673 3.095 April 3.690 3.783 May 3.271 2.718 June 2.700 3.932 July 2.661 3.657 Total 20.724 22.339 Avg. CMI 2.960 3.198

Inclusion/Exclusion Criteria Exclusion Inclusion • Non-English speaking • Critically ill patients patients housed in the two study • RASS score of -4 or -5 units • Patients who have been • English speaking adult in the ICU >4 months • Adequate Corrected • Lateral transfers: Hearing; able to follow Patient s transferred commands from intervention unit to • control unit Richmond Agitation- • Patients in first 12 hours sedation score (RASS) post surgery who had above -4 general anesthesia • Primary admission diagnosis new neurological event

Data Collection Methodology • Research Coordinator Assistant – Staff Nurse Documentation • Evidence-based Researcher-generated Tools – Delirium Data Collection Form – Significant Events Form • Valid & Reliable Instruments – Richmond Agitation-Sedation Scale (RASS) 1 – Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) 2 1 Sessler, C.N., Gosnell, M.S., Grap, M.J., et al. (2002). 2 Ely, E.W., Inouye, S.K., Bernard, G.R., Gordon, S., Francis, J., May, L., Truman, B., Speroff, T., Gautam, S.,Margolin, R., Hart, R.P., Dittus, R. (2001).

The Delirium Prevention Bundle Sedation Cessation (vents only ) Adequate Sleep Pain Promotion control Prevent or Reduce duration of delirium Meaningful Daily Progressive Sensory Mobility stimulation

Results

7S -1&2 7S-3 Control Unit Intervention Unit P value N (%) 512 (65.6) 269 (34.4) Female, n (%) 247 (48.5) 137 (50.9) 0.524 Race, n (%) 0.730 White, non-Hispanic 243 (49.2) 121 (46.7) African-American 175 (35.4) 90 (34.8) Asian 10 (2.0) 4 (1.5) Hispanic 56 (11.3) 38 (14.7) Other 10 (2.0) 6 (2.3) Age Categories, n (%) 0.524 <45 83 (16.2) 44 (16.5) 45-64 206 (40.3) 105 (39.3) 65-74 107 (20.9) 48 (18.0) 75-84 78 (15.3) 53 (19.8) ≥85 37 (7.2) 17 (6.4) # Co morbidities n(%) 0.017 <3 211 (41.2) 89 (33.1) 3-5 211 (41.2) 112 (41.6) >5 90 (17.6) 68 (25.3)

“0” delirium incidents > 1 Delirium Incident p No. Days on Mech. Vent, 527 (0.26) 0.16-0.35 254 (3.76) 3.04- <0.0001 n (mean)95%CI 4.49 No. Days in Restraint, 527 (0.06) 0.02-0.11 254 (2.65) 2.08- <0.0001 n (mean)95%CI 3.22 LOS in ICU >3 days, n (%) 134 (25.4) 162 (63.8) <0.001 No. Co Morbidities, n (%) <0.001 <3 232 (44.0) 68 (26.8) 3-5 214 (40.6) 109 (42.9) >5 81 (15.4) 77 (30.3) Female Gender n (%) 263 (50.0) 121 (48.0) 0.604 Age categories n (%) <0.001 <45 101 (19.3) 26 (10.2) 45-64 225 (42.9) 8 6(33.9) 65-74 94 (17.9) 61 (24.0) 75-84 81 (15.5) 50 (19.7) ≥85 23 (4.39) 31 (12.2) Days on Mech Vent >0, 63 (12.0) 128 (50.4) <0.001 n (%) Days in Restraint >0, 16 (3.04) 115 (45.3) <0.001 n(%)

Percent change in odds of delirium by day Treatment p-value for # Subjects 7S-1&2 7S-3 Effect, % treatment (Observa- Control Interven- effect tions) Unit tion Unit % % (p-value) (p-value) Unadjusted 668 (2687) +2.5 -4.8 -7.1 0.021 delirium model (0.13) (0.08) (p=0.11) Delirium model 668 (2687) +1.7 -6.1 -7.7 0.012 adjusted w age, co- (0.30) (0.025) morbidities, LOS variable (p<0.0001) Gender Male 344 (1319) +6.5 +1.4 0.29 -4.8 (0.02) (0.71) Female 321 (1344) -0.5 -11.2 -10.7 0.016 (0.81) (0.005) Age 65-74 139 (621) +10.4 -13.7 -21.9 <0.001 (0.02) (0.003)

Liver Disease No 597 (2326) +4.1 -4.9 -8.6 0.009 (0.02) (0.10) Yes 65 (328) -10.0 -6.5 0.67 +3.9 (0.06) (0.36) Any Kidney Disease 576 (2328) +2.7 -3.9 -6.5 0.041 No (0.12) (0.16) Yes 86 (326) +0.3 -22.5 0.086 -22.7 (0.97) (0.07) Co Morbidities <3 246 (928) +1.7 -11.0 -12.5 0.031 (0.47) (0.04) 3-5 277 (1126) +3.8 +11.8 0.18 +7.7 (0.13) (0.02) >5 145 (633) +1.6 -14.4 0.052 -15.6 (0.84) (0.002) History of Alcohol 230 (868) +1.4 -0.8 0.75 -2.1 No (0.61) (0.90) Yes 50 (162) +1.4 +64.6 0.15 +62.4 (0.92) (0.11) Optimum 49 (221) +9.1 -27.2 -33.3 <0.001 Conditions: Age 65- (0.002) (<0.001) 74, female, no liver disease

Table 14. Results from Longitudinal Logistic Regression Analyses – of Mobility Elements in Intervention Unit Only Percent change in odds of delirium by day Variables Coding No. Subjects Variable Codes Variable p-value Variable effect @ initial (Observations) No. Subjects (Observations) effect for status: (% change in del 0 1 variable odds, p-value) effect Mobility elements, 236(1016) -25.2(0.19) - +27.4 0.27 present? 14(19) 4.8(0.093) Code: (0,1) = (no, yes) 222(997) (-89, p=0.044) Turning every two 235(1006) - -4.4(0.13) +34.2 0.080 hours 28.7(0.046) 216(977) Code: (0,1) = (no, yes) 19(29) (-93.4, p=0.007) PROM exercises & 223(881) -27.4(0.15) -2.3(0.45) +34.5 0.18 active ROM per 21(27) 202(854) guidelines Code: (0,1) = (no, yes) (-86.7, p=0.049)

Table 15. Results from Longitudinal Logistic Regression Analyses – of Out-of-Bed Elements in Intervention Unit Only Percent change in odds of delirium by day Variables Coding No. Subjects Variable Codes Variable p-value Variable effect @ initial (Observation No. Subjects effect for status: (% change in del s) (Observations) variable odds, p-value) 0 1 effect Out-of-Bed elements, 235(1002) - -0.8(0.84) +6.2 0.14 present? 6.6(0.048) 180(488) Code: (0,1) = (no, yes) 55(514) (-64, p=0.002 ) Dangle at edge of bed 234(998) -5.0(0.08) -3.1(0.77) +2.1 0.84 w/feet planted 170(899) 65(99) Code: (0,1) = (no, yes) (+0.1, p>0.99) Active transfer to chair 234(1008) - -1.5(0.69) +5.8 0.17 (20 min TID) 6.9(0.034) 194(451) Code: (0,1) = (no, yes) 40(557) (-51.4, p=0.030) Ambulation & return to 235(1004) - +2.8(0.78) +8.7 0.41 bed (1 to 2 steps per 5.4(0.057) 61(94) day) Code: (0,1) = (no, 174(910) yes) (-62.1, p=0.066)

Table 10. Results from Longitudinal Logistic Regression Analyses – Adjusted for Effects of Selected Time-dependent Variables using only patients with GTE 2 days of non-missing delirium Percent change in odds of delirium by day Variables No. 7S-1&2 7S-3 Treatment p-value Subjects Control Intervention Effect, % for (Observati Unit Unit treatment ons) %(p-value) %(p-value) effect Unadjusted model 494(2513) +2.2(0.18) -5.4 (0.049) -7.4 0.017 LTD’s , adj. model 494(2513) +1.2(0.46) -1.6(0.57) -2.3 0.38 OR =4.61, p <0.001 Coded (0,1) = (<3, ≥3) LTDs <3 442(1578) -1.0(0.81) +2.3(0.60) +3.3 0.58 LTDs ≥3 187(935) +2.3(0.26) -8.8 (0.040) -10.9 0.018 Sedation Protocol, adj. model 104(493) +6.2 (0.023) +2.9(0.57) -3.4 0.59 OR = 1.81, p=0.34 Sed Prot = no 98(464) +6.1 (0.024) +2.9(0.574) -3.0 0.59 Sed Prot = yes 22(29) +792(0.33) -37.5(0.42) -92.1 0.31 Sed Prot = NA 473(1961) +2.4(0.39) -1.6(0.69) -3.9 0.41 Total Complications, adj. 494(2505) +4.0 (0.023) -4.2(0.13) -7.9 0.012 model OR = 3.86, p<0.001 Coded (0,1) = (0, >0) No. Comps = 0 453(1509) +6.7 (0.004) +3.7(0.53) -2.8 0.64 No. Comps >0 317(996) +3.0(0.37) -3.1(0.21) -6.8 0.12